Socioeconomic Disparities in Follow-up Care for Young Adults with Type 1 Diabetes and Impact on Glycemic Control

BACKGROUND: Only 13% of young adults (YA) with type 1 diabetes (T1D), nationally, achieve the American Diabetes Association glycemic target of <7%. YA with T1D of low socioeconomic status (SES) have incrementally worse glycemic control, due to personal, social, and healthcare system factors. Engagement in regular diabetes follow-up has been shown to be beneficial in preventing acute complications and improving glycemic control in YA with T1D, but little is known whether disparities exist in follow-up care based on SES. The purpose of this study was to a) compare differences in diabetes follow-up patterns between low and higher SES YA with T1D and b) evaluate the impact of interrupted care on glycemic control. METHODS: 203 YA with T1D, 18-30 years, were recruited from the adult diabetes clinic at the University of Pennsylvania. Demographic, clinical, and follow-up visit data were extracted from medical charts. Low SES individuals were defined as having medical coverage under a federal or state-sponsored (public) insurance plan while higher SES individuals were defined as having coverage under a commercial (private) insurance plan. Baseline demographic and clinical characteristics were compared by insurance type. Multilevel mixed effects logistic and linear regression models were used to compare differences in follow-up rates and the impact on glycemic control. All models were adjusted for age, sex, race, diabetes duration, insulin regimen, and time in diabetes providerﾒs care. RESULTS: 203 participants were included for analysis. Mean age was 23.5 years and 55% were female. Forty-six percent (n=95) had public insurance and 53% (n=108) had private insurance; 42% (n=40) of publicly insured YA were black compared to 11% (n=12) of privately insured YA. Mean diabetes duration was 11.8 years with no significant difference between publicly and privately insured. Mean overall HbA1c was 9.0%, with mean HbA1c 9.9% for publicly insured and 8.8% for privately insured (p<0.001). Publicly insured YA were 1.5 times more likely to no show for scheduled visits (OR=1.53, p=0.009) and were 2.3 times more likely to be lost to diabetes follow-up after 6 months (OR 2.3, p<0.001), compared to privately insured YA. Glycemic control worsened substantially with each successive no show to a scheduled visit (HbA1c +1.10% per no show, p=0.001). CONCLUSION: Low SES YA with T1D are less likely to consistently follow up in diabetes care, are more likely to be completely lost to diabetes care after 6 months, and have worse glycemic control as a result of inconsistent follow-up, compared to higher SES YA. Further research needs to explore why disparities in follow-up exist, as well as innovative healthcare delivery modalities.